Screening for poverty: identifying an important social determinant of health
“A 41 year-old woman with no documented medical history or family history of disease presents to you complaining of occasional chest pains on exertion. How many would order a stress test to rule-out cardiovascular disease?” asks Dr. Gary Bloch, to a captivated audience of resident physicians currently in training at an academic learning day – a few hands go up. “Now how about if she were a smoker or had high cholesterol?” – several more hands go up. “Now how about if I told you she earned less than $12 000 per year through part-time work, while renting a $600 per month bachelor apartment?” While some more put their hands up, many in the group look at each other, unsure of how this information would impact their diagnostic decision-making.
Dr. Bloch, a Family Physician at Toronto’s St. Michael’s Hospital and a founding member of Healthcare Providers Against Poverty (HPAP), is an advocate for poverty screening. “Just as screening is important for other conditions or risk factors, like smoking, high cholesterol or domestic violence, so too is screening for poverty,” he says. Dr. Bloch and HPAP have been instrumental in producing a primary care intervention tool on poverty that is now endorsed by the Ontario College of Family Physicians and will likely soon be made available to every Family Physician in the province for use in clinical practice.
So why bother with poverty reduction as a health intervention? According to Dr. Bloch, “…because the evidence shows that poverty is a major health condition and the biggest determinant of health, especially for those who live on low incomes.” One only needs to scratch the surface of the growing body of research evidence to see the importance of poverty on health outcomes. Poverty has been shown to account for 24% of person years-of-life lost in Canada, second only to 30% for neoplasms, out of all potential causes of illness. Further, the evidence showing the impact of poverty on the risk of a variety of diseases is quite diverse:
- Cardiovascular disease: there is a 17% higher rate of circulatory conditions among the lowest income quintile versus the Canadian average
- Diabetes: prevalence among the lowest income quintile of Canadians is more than double the rate in the highest income quintile
- Mental Illness: the suicide-attempt rate of those living on social assistance is 18 times higher than higher-income individuals
- Cancer: low-income women are less likely to access screening interventions like mammograms or Pap Smears
- Development: infant mortality is 60% higher in the lowest income quintile neighbourhoods
Regardless of this compelling evidence, why is there a need to screen for poverty? “Simply because we don’t know which patients live in poverty and if we don’t ask, we won’t find out,” says Dr. Bloch. With 29% of Toronto families and 20% of Ontario families living in poverty, it is not difficult to comprehend its impact on a significant portion of the population. Although the debate continues about how to exactly define the ‘poverty line’, the body of literature in existence supports the fact that income impacts health across a gradient with health effects becoming more profound at the bottom quintile of incomes. A February 2012 report by the Metcalf Foundation entitled, ‘The Working Poor in the Toronto Region’, highlighted the fact that the number of working people in the Toronto area unable to make ends meet grew by 42% between 2000 and 2005. It is clear that having full-time and year-round employment does not guarantee a poverty-free life and if we do not screen for poverty, we will not be able to identify it as a risk factor. Furthermore, we will not be able to adjust a patient’s health risk (e.g. risk of cardiovascular disease) in diagnostic decision-making, nor connect patients with organizations and resources that will assist them in maximizing their incomes (e.g. disability benefits, welfare supplements, tax credits, old age security, child benefits). Physicians that screen for poverty are in a unique position to suggest and provide opportunities for interventions that can increase income and thereby reduce the effect of poverty on health, while advocating for government policies that can improve income supports and reduce income inequality.
I look forward to the day when screening for poverty as a risk factor for health becomes the standard of practice in every setting, whether it be in the Emergency Room, on the wards of a hospital or in primary care clinics.
Naheed Dosani is a Family Medicine Resident with the Department of Community and Family Medicine at the University of Toronto and is training at St. Michael’s Hospital.